Early results after laparoscopic Roux-en-Y gastric bypass: effect of the learning curve.

INTRODUCTION: This study was performed to evaluate the safety and short-term efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity and to describe the relation between learning curve and short-term outcomes. METHODS: We collected a prospective database on the first 201 consecutive patients who underwent LRYGB by a single university-based, experienced bariatric surgeon over 24 months. We divided patients into 3 consecutive groups of 67 patients for analysis (Group 1, Group 2 and Group 3). RESULTS: The mean patient age was 37 (standard deviation [SD] 9) years; mean body mass index (BMI) was 49.2 (SD 8.3) kg/m2. BMI was similar in Groups 1 and 2 (mean 47.1, SD 5.9 and mean 48.7, SD 8.9 kg/m2) but increased in Group 3 (mean 52, SD 9.7 kg/m2, p < 0.01). Operative time decreased from 145 (SD 30) minutes in Group 1 to 114 (SD 24) minutes in Group 2 (p < 0.01) and was maintained at 119 (SD 23) minutes in Group 3. Early and late complication rates were 14.9% and 12.4%, respectively. Leak rates decreased from 6.0% in the first group to 1.5% in Groups 2 and 3, but they did not reach statistical significance. Anastomotic stricture rates decreased from 11.9% in Group 1 to 3.0% in Group 2 (p < 0.01). Overall excess weight loss for the entire series was 31.5% (SD 11.9%), 54.5% (SD 14.1%), 77.1% (SD 18.5%) and 82.1% (SD 17.5%) at 3, 6, 12 and 18 months, respectively. CONCLUSION: LRYGB can be performed with acceptable morbidity and short-term results during the learning curve. In our series, operative time and anastomotic stricture rates decreased with experience, despite an increase in mean BMI.     

Mechanisms of thrombin generation during surgery and cardiopulmonary bypass [see comments]

Although in vitro studies have been invaluable in revealing the complex biochemistry of the blood coagulation system, the mechanisms involved during the in vivo response to hypercoagulable stimuli are still unclear. We have used plasma-based enzyme-linked immunosorbent assays (ELISAs) to study the mechanisms by which the coagulation system is activated in vivo during human cardiopulmonary bypass (CPB) surgery (n = 8). A novel immunoassay for factor XIIa was used to detect activation of the contact system, factor IX activation peptide (FIXAP) was used as a marker for activation of factor IX, and prothrombin fragment F1 + 2 (F1 + 2) was used as a marker for thrombin generation. The ELISA for FIXAP is described for the first time herein. F1 + 2 levels increased early in response to surgical intervention: from a baseline of 38.7 +/- 9.7 ng/mL (mean +/-SE), levels increased rapidly during surgery and bypass to a maximum of 448.5 +/- 92.0 ng/mL. A modest yet significant increase in factor XIIa levels from 3.47 +/- 0.54 ng/mL to 4.33 +/- 0.85 ng/mL was evident during surgery before bypass, but no further significant increase was detected on establishing extracorporeal circulation. FIXAP levels demonstrated a small and late increase during surgery from 4.98 +/- 0.55 ng/mL to a maximum of 10.20 +/- 1.23 ng/mL, the increase beginning at the time of near maximal F1 + 2 levels. There was no association between activation of the contact system (factor XIIa levels) and the generation of thrombin (F1 + 2 levels). However, a strong association (r = .705) was apparent between the generation of thrombin (F1 + 2 levels) and activation of factor IX (FIXAP levels), despite the delay between the activation of prothrombin and factor IX. The data do not support the established view that contact activation resulting from exposure of blood to foreign surfaces is the major procoagulant stimulus in CPB. Instead, the results suggest that the main trigger to coagulation during CPB surgery was provided via the tissue factor-factor VIIa mechanism in response to the cutting of blood vessels, which directly activated factor X and then prothrombin. The late activation of factor IX, which presumably also contributed to maximal prothrombin activation, could have arisen due to direct tissue factor-factor VIIa action, or by secondary feedback action of thrombin on the intrinsic system.     

Health seeking and sexual behaviour among patients with sexually transmitted infections - the importance of traditional healers

We aimed to describe health seeking and sexual behaviour including condom use among patients presenting with sexually transmitted infections (STI) and, to identify socio-demographic and behavioural risk factors associated with “no condom use” during the symptomatic period. A cross-sectional study of consecutive new STI cases presenting at the district STI clinic in Thyolo were interviewed by STI counsellors after obtaining informed consent. All patients were treated according to National guidelines. Of 498 new STI clients, 53% had taken some form of medication before coming to the STI clinic, the most frequent alternative source being the traditional healer (37%). 46% of all clients reported sex during the symptomatic period (median=14 days), the majority (74%) not using condoms. 90% of all those who had not used condoms resided in villages and had seen only the traditional healer. Significant risk factors associated with “no condom use” included: visiting a traditional healer; being female; having less than 8 years of school education; and being resident in villages. Genital ulcer disease (GUD) was the most common STI in males (49%) while in females this comprised 27% of STIs. These findings, especially the extremely high GUD prevalence is of particular concern, considering the high national HIV prevalence in Malawi (9%) and the implications for STI and HIV transmission. There is an urgent need to integrate traditional healers in control activities, encourage their role in promoting safer sexual behaviour, and to reorient or even change existing strategies on condom promotion and STI control.     

Cost-effectiveness of expanded human immunodeficiency virus-testing protocols for donated blood

BACKGROUND: This study was designed to estimate the cost-effectiveness of expanding the human immunodeficiency virus (HIV)-testing protocol for donated blood beyond screening for HIV antibodies to further reduce the risk of HIV transmission through transfusion. STUDY DESIGN AND METHODS: A Markov decision analysis model was developed to estimate the cost-effectiveness of HIV antibody testing (at a cost of $5/unit) and of adding to that protocol a second HIV test, either plasma p24 antigen detection or RNA polymerase chain reaction (PCR) (at costs of $5/unit and $8/unit, respectively). Test efficacy was projected from anticipated window-period reductions (6 days for p24 antigen, 11 days for RNA PCR), and donor seroconversion rates were derived from the Retrovirus Epidemiology Donor Study. RESULTS: On the basis of current estimates of HIV prevalence rates in blood donors (1/10,000) and 16 million annual transfusions in the United States HIV antibody testing prevents 1568 cases of transfusion-acquired HIV infection each year at a cost of $3600 per quality-adjusted year of life saved. The addition of p24 antigen testing would prevent 8 more cases at a net additional cost of $60 million annually ($2.3 million/quality-adjusted life year); RNA PCR testing would prevent 16 more cases at a net additional cost of $96 million annually ($2.0 million/ quality-adjusted life year). CONCLUSION: Although expanding the donor HIV screening protocol with p24 antigen or RNA PCR testing will prevent rare cases of transfusion- associated HIV, the cost-effectiveness of such an addition is predicted to be far below that of most medical interventions. Thus, HIV test protocol additions are unlikely to provide cost-effective improvements to blood safety in the United States.     

大学生自尊特点与性别、年级及心理因素的关系

目的:观察大学生自尊水平的特点。方法:于2005-11/2006-05选取江西省内6所高等院校,专业包括理工科、医学、师范类及文科类大学生793名。以751名大学生为研究对象,采用二维自尊量表进行调查,包含16个题项,每个维度8个题项。量表的重测信度为0.84和0.80,同质性信度为0.86和0.84;该量表测量整体自尊,分为自我喜欢和自我能力感两个维度。采用个别访谈的方法对自尊高分同学和自尊低分同学进行个别访谈,同时收集同学和班主任(辅导员)对该同学的评价。调查中使用半结构化访谈,访谈提纲的内容是依据症状自评量表各因子结合以往研究中自尊及其相关影响因素设计的,主要包括以下3个方面:①与焦虑有关的认知和事件。②与同学、老师以及朋友的关系。③对自我情感和心境的评价。为了缓解被访谈者的紧张情绪,还进行其他方面的交流。结果:发放问卷793份,收回780份。对所收回的问卷进行初步整理,剔除不符合要求的废卷后,获得有效问卷751份。①男生在整体自尊和自我能力感维度上得分高于女生,差异有显著性意义[分别为(49.5820±7.9979),(48.2091±8.2642)分;(23.3893±3.9680),(22.6963±4.2606)分,t=2.157,2.134,P<0.05]。男女生在自我喜欢维度上得分差异无显著性意义(P>0.05)。②在整体自尊和自尊两个维度上,各年级之间差异有显著性意义(P<0.05)。大二学生自我喜欢维度得分明显高于大一和大三学生[分别为(26.7353±5.1527),(25.2432±4.7695),(25.6045±5.2917)分,t=3.485,2.11,P<0.05,0.01];大二学生在自我能力感维度得分明显高于大一和大三学生[分别为(23.5588±4.2219),(22.5459±4.2285),(22.9718±3.9448)分,t=2.748,1.395,P<0.05,0.01]。③整体自尊和自尊两个维度,在性别与年级之间有交互效应。整体自尊和自我喜欢得分男生高于女生,大二学生得分高于大一和大三学生。自我能力感得分大二女生高于男生。在整体自尊和自尊两个维度,年级和专业之间有交互效应。④自尊与心理健康的关系:整体自尊高分者普遍具有正确的人生态度,满意的心境,对生活乐观,对未来充满了希望,和谐的人际关系、良好的个性和高尚的人格,同学之间关系融洽,能很好地相处,在与人交往中能做到尊重人、理解人,从不将自己的观点强加到他人的身上,能够平等地、宽容地了解、评价对方。而整体自尊低分者普遍存在焦虑情绪,人际关系不和谐和不能恰当地认同自己,或是莫名其妙地自傲,或是无缘无故地自卑,经常有意无意地掩饰自己的不足,心理特别敏感、脆弱,失落感极强,经不起风浪的折腾,存在严重的心理冲突,回避矛盾,无法保持平衡的心理状态。结论:大学生自尊水平存在性别、年级差异,并与心理健康症状存在明显相互作用关系。     

腰椎间融合术

正ISBN-10:0323476635ISBN-13:978-0323476638Elsevier出版社2018年11月出版240页本书由腰椎间融合术(lumbar interbody fusion,LIF)领域资深外科专家及主要技术革新者编撰,重点阐述微创及开放LIF手术技术的最新进展,全面介绍极外侧、斜外侧、直接外侧入路以及横突间入路、轴向入路和内窥镜下入路等成熟入路方式的具体步骤。本书有如下特点:注重技术差异、每一术式优缺点以及并发症的防治手段;高质量影像     

Safety of blood donations following a natural disaster

To evaluate the relative safety of blood donations given in response to a major disaster, donor demographics and infectious disease test results were compared for donations made during the 10 days following the October 17, 1989, San Francisco Bay Area earthquake and those made during the preceding 6 months. These comparisons were made for donations given to the regional blood center in the area that was immediately affected by the disaster (Irwin Memorial Blood Centers) and for those given in an unaffected region (Los Angeles/Orange Counties Region, American Red Cross Blood Services). The rate of donation increased more than 200 percent during the 5 days following the earthquake in both the disaster-affected and unaffected regions. Both the disaster-affected and unaffected regions observed significant increases in the proportions of donations by first-time donors, by persons aged 20 to 39 years, and by women. The rates of confirmed positivity for infectious disease markers for post-earthquake donations did not differ significantly from rates for homologous donations given during the preceding 6 months, particularly when the rates were adjusted for the increased representation of first-time donors. Approximately 39 percent of post-earthquake first-time donors gave blood again within the following 6-month period. It is concluded that donations given after major disasters are essentially as safe as routine donations and that active efforts to recruit these donors again can be undertaken without reservation.